Leda Tomiko Yamada da Silveira

Ventilação não invasiva com pressão positiva pós-extubação: características e desfechos na prática clínica.

Objective To describe postextubation noninvasive positive pressure ventilation use in intensive care unit clinical practice and to identify factors associated with noninvasive positive pressure ventilation failure. Methods This prospective cohort study included patients aged ≥ 18 years consecutively admitted to the intensive care unit who required noninvasive positive pressure ventilation within 48 hours of extubation. The primary outcome was noninvasive positive pressure ventilation failure. Results We included 174 patients in the study. The overall noninvasive positive pressure ventilation use rate was 15%. Among the patients who used noninvasive positive pressure ventilation, 44% used it after extubation. The failure rate of noninvasive positive pressure ventilation was 34%. The overall mean ± SD age was 56 ± 18 years, and 55% of participants were male. Demographics; baseline pH, PaCO2 and HCO3; and type of equipment used were similar between groups. All of the noninvasive positive pressure ventilation final parameters were higher in the noninvasive positive pressure ventilation failure group [inspiratory positive airway pressure: 15.0 versus 13.7cmH2O (p = 0.015), expiratory positive airway pressure: 10.0 versus 8.9cmH2O (p = 0.027), and FiO2: 41 versus 33% (p = 0.014)]. The mean intensive care unit length of stay was longer (24 versus 13 days), p < 0.001, and the intensive care unit mortality rate was higher (55 versus 10%), p < 0.001 in the noninvasive positive pressure ventilation failure group. After fitting, the logistic regression model allowed us to state that patients with inspiratory positive airway pressure ≥ 13.5cmH2O on the last day of noninvasive positive pressure ventilation support are three times more likely to experience noninvasive positive pressure ventilation failure compared with individuals with inspiratory positive airway pressure < 13.5 (OR = 3.02, 95%CI = 1.01 - 10.52, p value = 0.040). Conclusion The noninvasive positive pressure ventilation failure group had a longer intensive care unit length of stay and a higher mortality rate. Logistic regression analysis identified that patients with inspiratory positive airway pressure ≥ 13.5cmH2O on the last day of noninvasive positive pressure ventilation support are three times more likely to experience noninvasive positive pressure ventilation failure.

The effects of recruitment maneuver during noninvasive ventilation after coronary bypass grafting: A randomized trial

Objective: Pulmonary impairment is a common complication after coronary artery bypass graft procedure and may be prevented or treated by noninvasive ventilation. Recruitment maneuvers include sustained airway pressure with high levels of positive end‐expiratory pressure in patients with hypoxemia, favoring homogeneous pulmonary ventilation and oxygenation. This study aimed to evaluate whether noninvasive ventilation with recruitment maneuver could safely improve oxygenation in patients with atelectasis and hypoxemia who underwent a coronary artery bypass grafting procedure. Methods: Thirty‐four patients admitted to our intensive care unit undergoing mechanical ventilation after surgery, with ratio of arterial oxygen partial pressure to fraction of inspired oxygen < 300 and radiologic atelectasis score ≥2, were included. The control group consisted of 16 randomized patients and the recruitment group consisted of 18 patients. After extubation, noninvasive ventilation was applied for 30 minutes 3 times a day with positive end‐expiratory pressure of 8 cm H2O. The recruitment group received recruitment maneuver with positive end‐expiratory pressure of 15 cm H2O and 20 cm H2O for 2 minutes each during noninvasive ventilation. We analyzed the arterial oxygen partial pressure in room air, radiologic atelectasis score, hemodynamic stability, and adverse events from extubation until discharge. Results: Arterial oxygen partial pressure increased 12.6% ± 6.8% in the control group and 23.3% ± 8.5% in the recruitment group (P < .001). The radiologic atelectasis score was completely improved for 94.4% of the recruitment group with no adverse events, whereas 87.5% of the control group presented some atelectasis (P < .001). Conclusions: Noninvasive ventilation with recruitment maneuvers is safe, improves oxygenation, and reduces atelectasis in patients undergoing coronary artery bypass.

Decline in functional status after intensive care unit discharge is associated with ICU readmission: a prospective cohort study

OBJECTIVES To compare the functional status at intensive care unit (ICU) discharge of patients who were later readmitted to the ICU and patients discharged home and to verify whether a decline in functional status is associated with ICU readmission. DESIGN Prospective cohort study. SETTING ICU at a tertiary teaching hospital. PARTICIPANTS Patients admitted to the ICU, ≥18 years old, submitted to invasive mechanical ventilation (IMV), and discharged to the ward. INTERVENTIONS Functional assessment at ICU discharge. Discharge Group (DG) (patients discharged home) and Readmission Group (RG) (patients who returned to the ICU) were compared with Mann-Whitney and Chi-square or Exact Fisher tests. Multiple logistic regression verified association. MAIN OUTCOME MEASURES Barthel Index, key pinch strength, clinical and demographic data. RESULTS Patients in the readmission group presented lower Barthel Index [Median 40 (IQR 20-75) vs 60 (33-83), P=0.033], greater relative variation (pre and post ICU) of the Barthel Index (P=0.04), lower key pinch strength [3.4 (1.8-4.5) vs 4.5 (2.7-6.8)kg·f, P=0.006] and higher APACHE II [18 (12-22) vs 15 (11-20), P=0.027]. Multiple regression found that the relative variation of the Barthel Index was independently associated with ICU readmission (P<0.001), as well as higher APACHE II (P=0.020), shorter IMV duration (P<0.001) and ICU admission without clear diagnosis (P=0.020). The Hosmer-Lemeshow test indicated good adjustment of the model (P=0.99). CONCLUSION Readmitted patients presented poorer functional status and lower pinch strength. Relative variation of the Barthel Index was associated with ICU readmission despite other factors, as was higher APACHE II, shorter IMV duration and admission without clear diagnosis. TRIAL REGISTRATION NUMBER Not applicable.

Assessing functional status after intensive care unit stay: the Barthel Index and the Katz Index

Objective To assess the functional status of post-ICU patients using the Barthel Index (BI) and the Katz Index (KI) and to assess which is more suitable for this population. Design Retrospective longitudinal study. Setting Public tertiary hospital in São Paulo (Brazil). Participants Patients aged ≥18 years old, admitted to ICU, who were treated with mechanical ventilation (MV) ≥ 24 h and were discharged to ward. Exclusion criteria Inability to answer the BI and the KI; limiting neurological or orthopaedic conditions; ICU stay ≥90 days. Patients transferred to or from other hospitals or who died in the wards were not analysed. Intervention BI and KI were scored pre-ICU and post-ICU and the variation was calculated. Main Outcome Measures BI and KI scores were compared using analysis based on item response theory (IRT), using degree of difficulty and discriminating items as parameters. Results Median age was 52 years old, median APACHE II score was 15. Median ICU stay was 11 days and median MV duration was 4 days. BI variation was 44% and KI variation was 55%. In IRT analysis, BI considered a larger number of items with different levels of difficulty. Conclusion Both the BI and the KI revealed significant deterioration of functional status after ICU discharge. The IRT analysis suggested that the Barthel Index might be a better scale than the Katz Index for the assessment of functional status of patients discharged from ICU, since it presented better discrimination of the ability to carry out the tasks.

Resposta para: Ventilação não invasiva com pressão positiva pós-extubação: características e desfechos na prática clínica

The authors gratefully acknowledge the comments made by the researchers. We will analyze the methodologies currently used by our group and the cited studies to understand the differences described in the letter. Additionally, we would like to emphasize that the study was a prospective cohort study, in which the researchers collected data on a daily basis from the hospital specialty units included in the study. The hospital where the study was conducted is part of the largest hospital complex in Latin America. It is a high complexity tertiary care hospital located in Sao Paulo city. This factor contributed to the heterogeneity of the study population because many units with different specialties were included. In our study,(1) the parameters of noninvasive ventilation (NIV) that were evaluated were collected on the last day of NIV use, i.e., the day of NIV withdrawal due to either success or failure. The parameters at the time of collection were recorded and compared. In the impressive clinical trial reported by Esteban et al.,(2) NIV was applied upon detection of acute respiratory failure, and the parameters used were adjusted according to the tidal volume and expected respiratory rate. We believe that in a clinical trial, the parameters are more controlled and that the methodology of that trial did not detail when and how the inspiratory pressure parameters were collected. In the study by Rana et al.(3) the parameters were collected four times daily, and their median values were analyzed. In contrast, our study evaluated the parameters collected on the last day of NIV use. Another important distinction of our study was the population. Rana et al.(3) studied a very specific population that had severe disease (acute lung injury and acute respiratory distress syndrome). Regarding the study by José et al.,(4) the authors reported contrasting results to those published by Esteban et al.(2) However, the study designs were very different because José et al.(4) performed a prospective study with no control group and no randomization, which are factors that weakened their results. We consider the results obtained in clinical practice to be of greater importance. We believe that from these data, we can plan new controlled and randomized clinical trials to further evaluate the hypothesis. We will try to strengthen the hypothesis in future studies by carefully evaluating the parameters of inspiratory positive airway pressure and expiratory positive airway pressure to identify possible markers for detecting the interruption of NIV in cases of failure. Resposta para: Ventilação não invasiva com pressão positiva pós-extubação: características e desfechos na prática clínica

Quality of life of critically ill patients in a developing country: a prospective longitudinal study

[Purpose] To evaluate the quality of life of critical illness survivors in a developing country over the time after hospital discharge and to assess the influence of clinical variables on quality of life. [Subjects and Methods] A prospective longitudinal study was conducted in a large, tertiary, public hospital in Sao Paulo, Brazil. We included patients ≥18 years old, hospitalized in the intensive care unit with ≥24 hours of invasive mechanical ventilation. Quality of life was assessed using the Medical Outcomes Study 36-Item Short Form Health Survey, which was applied by telephone interview at the first, third and sixth months after hospital discharge. [Results] 75 patients were included in the study. Quality of life improved progressively after hospital discharge; role-physical was the most compromised domain. The physical component was influenced by the age. Quality of life was not influenced by Apache II categorization, length of invasive mechanical ventilation, intensive care unit stay or hospital stay. [Conclusion] Survivors of critical illness in a developing country present poor quality of life, which improves over time. Age influenced the physical component of quality of life.